Solicitation No. DTFASA-17-R-00617 - Qualification Inquiry Lautenberg Amendment Form.pdf

DTFASA-17-R-00617

ATTACHMENT J.6

QUALIFICATION INQUIRY

LAUTENBERG AMENDMENT

In completing this form, you are advised:

The purpose is to obtain information that will assist in the determination of whether personnel reassignment and/or administrative action are warranted.

You have a duty to complete this form. Agency disciplinary action, including dismissal, may be undertaken if you refuse to answer or if you fail to reply fully and truthfully.

Neither your answers nor any information or evidence gained by reason of your answers can be used against you in any criminal prosecution for a violation of Title 18, United States Code, Section 922(g)(9). However, the answers you furnish and any information or evidence resulting there from may be used against you in a prosecution for knowingly and willfully providing false statements or information, and in the course of agency disciplinary proceedings.

Have you ever been convicted of a misdemeanor crime of domestic violence within the meaning of the statute?

Initial and date: YES________________ NO_________________ If you answered YES to the question, provide the following information with respect to the conviction.

Court/jurisdiction: ___________________________________

Docket/Case Number: ____________________________________

Statute/Charge: _____________________________________

Date Sentenced ______________________________________

I hereby certify that, to the best of my information and belief, all of the information provided by me is true, correct, complete, and made in good faith. I understand that false or fraudulent information provided herein may be grounds for adverse action, up to and including removal, and is also criminally punishable pursuant to federal law, including 18 USC Section 1001.

Name: ________________________________________ (print or type)

Duty Station _________________________________________ Signature Date